Documentation Clinical Notes - Copy (2)

Rehabilitation Clinical Documentation
5/13/2015 Dr. Charles Curtis MS, PT,DPT, MDT 1

 The goals aligned with the patients plan of care
are based on the patient centered functional
goals.

 Long Term Goal:
 The clinical goals are expected to be achievable and
realistic within the designated time frame and the
treatments listed (referred to as the treatment plan)
are necessary to achieve these goals within the
designated time frame.

 The functional goals were created based on the
reported patient’s prior level of function as
compared to the assessed current level of
function.
 Goals are Identified by:
 Valid and Reliable functional test
 Objective measures
 Co-morbidities
 Therapist judgment

 Test is measuring what it is intended to
measure
 Balance
 Dizziness
 Back Pain
 Neck Pain
 Leg function
 Arm function

 Broadly defined:
 One is able to rely on the test scores being accurate
and reproducible

 Data that are measureable
 Impairments
 Strength
 Pain
 Range of Motion
 Reflexes
 Circumference measures
 Function
 Functional Tests
 TGUG
 Berg
 Questionnaires
 Oswestry
 Neck Disability Index

 Issue that affect the outcome of treatment
 Age
 Past Medical History
 Family participation
 Cognitive Issues
 Access to attend PT
 Equipment needs

 To determine functional status or level of
disability the following must be considered
 Prior Level of Function
 Severity of Procedure/Pathology/Disease
 Objective Impairment Finding
 Functional Test(s) scores and the consideration of the
minimally detectable change and cut offs
 Motivation of patient and family
 Experience of therapist

 Outcomes Assessment
 Collection and recording of information
relative to health processes
 Outcomes Management
 Using information in a way that
enhances patient care
(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical
Application of Outcomes Assessment, Stamford Connecticut,
Appleton & Lange, 2000)

 Outcomes in clinical practice provide the
mechanism by which the health care provider,
the patient, the public, and the payer are able to
assess the end results of care and its effect upon
the health of the patient and society.
 (Anderson & Weinstein, 1994).

 To survive, in fact to flourish, in this era of
accountability health care providers must be
prepared to maintain and be able to provide
appropriate documentation and patient records
in a clinically efficient and economical manner.
 (Hansen, 1994).

 With the dawning, of the “era of
accountability,” there are new social mandates
directed toward health care providers and
health-related facilities. Measurements of
quality, satisfaction, efficacy, and effectiveness
now serve as essential elements for health care
decisions and matters of health policy.
 (Hansen DT, Mior S, Mootz RD in Yeomans SG: The
Clinical Application of Outcomes Assessment,
Stamford Connecticut, Appleton & Lange, 2000)

 Health Care Customer - Meaning of Outcomes
 Payers-purchasers Cost containment
 Regulators HCP compliance
 Administrators Efficiency-low utilization
 Clinical Researchers Proof of a premise
 Outcomes Experts Patient’s benefit
 Health Care Providers Clinical-Health Status
 (Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical

 Utility Is it useful?
 Reliability Is it dependable?
 Validity Does it do what it is supposed to?
 Sensitivity Can it identify patients with a
condition?
 Specificity Can it identify those that do not
have the condition?
 Responsiveness Can it measure differences
over time?

 Questionnaires
 General health status
 Pain
 Functional status
 Patient satisfaction
 Physiological outcomes
 Utilization measures
 Cost measures

 When outcome measures are appropriately
used and integrated into an evidence-based,
patient-centered model of practice, there is
accountability and quality assurance.
 (Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical

 Subjective outcomes assessment information is
gathered by the patient in self-administered
questionnaires and scored by either the:
 health care provider
 staff members or
 by a computer.

 In spite of the definition associated with the
term “subjective,” these “pen-and-paper tools”
have been described as very valid and reliable
– in many cases more so than many of the
“objective’ tests that health care providers have
relied upon for years.
 (Chapman-Smith, 1992; Hansen, 1994; Mootz, 1994).

 It must be emphasized that although the term
“subjective” carries negative connotations,
the reliability/validity data published
regarding these methods of collecting
outcomes is exceptional, typically out-
performing the test-retest reliability and
validity of most “objective” physical
performance tests.
 (Chapman-Smith, 1992).

 Subjective
(Patient Driven)
 General Health
 Pain Perception
 Condition or Disease
Specific
 Psychometric
 Disability Prediction
 Patient Satisfaction
 Prior Level of
function
 Objective
(HCP Driven)
 Range of Motion
 Strength - Endurance
 Nonorganic
 Proprioception
 Cardiopulmonary
 Developmental
 Neurological
 Pain (VAS)
 Integumentary
 Special Test
 Functional Tests

 It is important to remember to
utilize the same outcome
assessment tool through the
course of case management
with each patient.

 Progress Note
 Re-assessment
 Re-evaluation

 The progress notes allows the therapist to
determine the effectiveness of the allocated
plan of care and to measure the clinical
findings that are compared to the clinical goals
that establish indicators of progress toward
addressing functional limitations and
achieving functional goals.
 Falls hand and hand with the Re-assessment

 A re-evaluation is performed when a
significant changes has taken place and there
is an alteration in the plan of care.
 Be careful not to over-utilize this code in your
billing methodology

 The functional goals are based upon a
correlation of functional assessment tools,
clinical findings/tests, performance based
tests, objective findings and the therapist
judgment call.

 Impairment:
 Loss or abnormality of anatomical, physiological, mental, or
psychological structure or function. Organ specific
 Functional Limitation
 Restriction of ability to perform, at the level of the whole
person, a physical action, task or activity in an efficient,
typically expected, or competent manner. Person specific.
 Disability:
 The inability to perform or a limitation in the performance of
actions, tasks, and activities usually expected in specific social
roles.
(Nagi, S. Some conceptual issues in disability and rehabilitation. In : Sussman M, ed Sociology and
Rehabilitation. Washington DC: American Sociology Society; 1965: 100-113)

 APTA has numerous publication that address
components of clinical documentation. Below are a list
of three publications that will be discussed.
 Guide to Physical Therapy Practice
 Peer Review/Utilization Review
 Task Force on Measurements
 APTA Standards of Tests and Measurements
 Primer on Measurement: An introductory guide to
measurement issues. (Rothstein, Echternach)
 WHO: International classification of functioning, disability and
health

Documentation
Justification
PLOF to
CLOF
Impairments
linked
To Function
Outcomes
Measured
Patient
Center
Functional
Goals
Test: valid
and
Reliable

Dr. Charles Curtis MS, PT,DPT, MDT31
Validity and Reliability. Concurrent
and Retrospective Reviews
5/13/2015

 Provide services to patients/clients who have
impairments, functional limitation, disabilities
or changes in physical function and health
status resulting from injury, disease or other
causes.
(Guide to Physical Therapy Practice 2nd Edition. pg S31)
Dr. Charles Curtis MS, PT,DPT, MDT 325/13/2015

 What is needed for Review
 The inclusion of the patient in establishing goals:
 Patient centered functional goals
 A statement of impairment related to functional
limitation
 Valid Function Tests with reliable scores
 A statement on any changes in health status, wellness,
and fitness needs to be identified
 Objective noted with impairment measures
 Medicare signed plan of care
 Physician signature
 MD script for most commercial products
 Direct access does not require us to have a script just
communication with patient’s physician

 To set criteria for the effectiveness and
efficiency of a test Peer Review articles are
defined:
 Peer-review scientific studies published in, or in
accepted for publication by, medical journals that
meet nationally recognized requirements for
scientific manuscripts and that submit most of their
published articles for review by experts who are not
part of the editorial staff.

 Scope of practice is a key component to keep in mind
as to what services a PT should provide.
 Valid and Reliable Measure are an essential part of
clinical documentation.
 Scientific literature is the source of information
regarding the application of tests and how to interpret
the findings
 Validity: is the test measuring what it claims to
 Reliability: is the test consistent and stable and
reproducible.

View on Documentation and Function
5/13/2015

 Utilization Review Process Defined
 The review to determine whether health care
services that have been provided, are being
provided or are proposed to be provided to a
patient, whether undertaken prior to, concurrent
with or subsequent to the delivery of such services
are medically necessary.

 Concurrent Review Defined:
 The review preformed at the time of treatment.
 Review is performed to determine medical necessity
of the treatment performed and it effect on the
 consequence of disease , including
 impairments,
 functional limitations,
 patient centered functional goals that justify treatment,
which lead to the foundation of
 medically necessary.

 The fact that a provider and or physician (par
or non par) has made a prescribed,
recommended, or approved a service, supply
or equipment, does not in itself, makes it
medically necessary.
 What is required:
 Justification through written documentation
utilizing measurement that are valid and reliable
 These are the items that are required by a majority
of Utilization review process

 What is required by parties interested in
documentation?
 Proof that care is necessary, effective and important
to the patient.
 How do we do this?
 At the core of proper documentation is the validity and
reliability of the measurements. Linking these
measurement changes, from an impairments view and
the direct association to the functional limitation, of the
patient.

 According to Peat and Campbell (1979)
 “…the profession (physical therapy) has been
criticized for not objectively recording events”
 Why:
 Primary tools in the assessment of motor performance
are visual tools and gross motor test.
 Visual test disadvantage is the absence of
quantification of specific parameters of the event
 The validity of the test is placed on the therapist
personal observation a particular response.

 To improve our clinical documentation there
must be:
 An emphasis on function we must be able to analysis
performance
 An analysis of performance is the quantification of
stipulated parameters,
 comparison of parameters with respect to a normative
data,
 comparison of the present and previous states of results
for the same set of parameters.

 In the analysis of motor performance look to
two components:
 Product or outcome
 Effectiveness
 Efficiency
 Process
 Biomechanical efficiency
 Biomechanics is the science of accelerations, forces, and
displacements acting on the human body and the
injuries caused by these forces

 Effectiveness:
 The degree of success attained in the achievement of
the goal
 Efficiency:
 Ratio of mechanical work accomplished by the total
work accomplished (How much effort to how much
work). Directly related to time, distance, force and
accuracy.

 Biomechanical efficiency
 Skill of task.
 Exhibited by patient when attempting to perform a
movement
 Gross measurement (ie. Gross gait pattern)

 The human body is subject to gravitational
force and through the study of these force we
can maintain or improve a humans overall
quality of life.
 Any injury to, or lesion in, any of the
individual elements of the musculoskeletal
system will change the mechanical interaction
and cause degradation, instability or disability
of movement.

 In response to these negative adaptations:
 proper modification, manipulation and control of
the mechanical environment can help prevent injury,
correct abnormality, and speed healing and
rehabilitation.
 To Accomplish this,
 an understanding the biomechanics and loading of
each element during movement using visual
assessment and or motion analysis is helpful for
studying disease etiology, making decisions about
treatment, and evaluating treatment effects

 Proper documentation should follow the same
outline as analysis of movement:
 Effectiveness of a functional task should be
measured by the degree of success attained by the
achievement of the task or activity
 Efficiency of a functional task to measure time,
distance, force or energy required and accuracy of
the task. (RPE example of measuring this)

 All areas including, research, health care policy
reimbursement practices and the standards of
accrediting bodies all support writing patient-
centered functional goals.
 Reason:
 It promotes a patient-centered approach in which PT
actively facilitate the participation of the
patient/client, family, significant other and
caregivers in the plan of care.

 Rational for such goals:
 Functional Goals are necessary to address the fact
that correction of impairment alone is not directly
functional and may not necessarily lead to
functional improvements or may not be meaningful
to the patient.

 Function: those activities identified by
individual as essential to support physical,
social, and psychological well being and to
create a personal sense of meaningful living.
 Goals: remediation of impairment and uses the
term “outcomes” for minimization of
functional limitation, optimization of health
status, prevention of disabilities, and
optimization of patient/client satisfaction.
 Primary goal is to maintain and improve the
quality of life of an individual—
 empowering independency

 Defined: as the individually meaningful
activities that a person cannot perform as a
result of an injury, illness or congenital or
acquired condition, but want to be able to
accomplish as a result of physical limitation.

 The shift in federal guidelines of cost
reimbursement have alternatively benefited,
bewildered and penalized the clinics.
 The potential shift to a dependency of
reimbursement on the evidence based practice
will be required to utilize and document
credible measures of outcomes.
 Why? to safe guard our patients interest and to
promote our own professional self interest

 Appropriate question to identify patient
centered functional goals.
 Determine the patients desired outcomes
 Rank outcomes in priority order. (Ask patient which
of their goals is the most important)
 Develop an understanding of patients self care,
work, and leisure activities and environment in
which these activities occur (Life style, hobbies,
activity levels, etc.)
 Establish goals with the patient and if necessary
with family that relate to desired outcomes.

 Hypothesis Orientated Algorithm for
Clinicians II (HOAC II)
 A new decision making and documentation guide in
physical therapy.
 It is to serve as a template for documentation and as
a conceptual model for decision making and
therefore, could link documentation and practice.

 Algorithm presented provide a problem
solving approach to clinical decision
 Divides patient problems into two categories
 Patient identified problems (PIP):
 Non patient identified problems
(NPIP):

 Consist of functional limitations and
disabilities identified by patient, will
often exist when therapist is performing
initial evaluation, however these items
can also be anticipated by the therapist.
 Generated before examination, therefore
driven by patient.

 Problems that may occur (Risk Factors)
or existing problems not expressed by
the patient, but found by therapist.

 Testing Criteria
 Used to examine correctness of hypothesis related to problems
that currently exist. Informs us of the level of performance that
a patient needs to achieve to eliminate a problem (impairment
and functional limitation).
 Predictive Criteria
 Measured for anticipated problems. How long intervention for
prevention should be carried out. A focus on risk factors that
lead to corrective hypothesis, reduced risk factors. These are
not goals because they are worth achieving only if sufficient
evidence indicates that a problems might occur.

 HOAC II:
 prevention activities are goal driven and are planned
for specified period of time, therapists can, through
use of the algorithm, identify to payers the resources
they will need to achieve prevention.

 With two types of problems two types of
hypotheses are needed (Evidence-Based
Preferred or Logic as to the need)
 Existing Problems Hypotheses: requires hypotheses
about the diagnosis that detail what needs to be
changed to eliminate existing problems.
 Anticipated Problems: Elimination of risk factors
and a case as to what may happen with out
intervention.

 Rational for the intervention to avoid a
problem is difficult. Must look to the risk
factors and the removal of such.
 Epidemiological base
 Augmentative / Logic base with some type of
scientific basis
 Justification is critical with this type of problem.

 Goals: To base a goal on the change in
impairment is almost always inappropriate
 Goals should represent meaningful
accomplishments. Changes are functional

 The simplest way of checking whether a goal is
appropriate
 Whether the payer would find therapy to be
worthwhile if this is all that is achieved
 Whether anyone would feel therapy was worthwhile
if this is all that was achieved
 Commit to a evaluation schedule, identifiable
time lines when status of patient will be
checked

Dr. Charles Curtis MS, PT,DPT, MDT 66
Provide measurement tools to clinical
personnel and qualify existing
documents, training and competency
Make all clinical personnel accountable
to documentation requirements
Quality assurance preformed on
documentation (Peer Review ¼’ly) with
reports and action plans. Included in
yearly review
5/13/2015

 Improve the field of physical therapy
 Improve the quality of care to patients
 Improve efficiency and effectiveness of care
with closer monitoring
 Reduce denials for utilization review
 Add to evidence based practice data base with
published outcomes
 Provide data to potential clients

Points to Remember
 Document all objective data on evaluation
 Compare prior level of function to current level
 Medicare looks at a 90-180 day as the time line.
 Link all functional limitations with impairments
 Re-measure often to determine effectiveness
 Use measurements that are valid and reliable
 All goals should be patient centered, realistic and functional.
 Good documentation leads to justification of treatments that
leads to improved quality of care to patients

1) Six minute walk test (pulmonary/cardiac)
 Olsson L, Swedberg K. Eur Heart J. 2005 Oct;26(20):2209. Epub 2005 Aug 16.
2) DASH (upper extremity)
Deshmukh, AV et al. Total shoulder arthroplasty: Long-term survivorship, functional outcome,
and quality of life. J Shoulder Elbow Surg. 2005 Sep-Oct;14(5):471-9.
3) Oswastry (low back)
Ostelo, RW, de Vet HC. Clinically important outcomes in low back pain.
Best Pract Res Clin Rheumatol. 2005 Aug;19(4):593-607. Review
4) Neck index
Wlodyka-Demaillle, S.The ability to change of three questionnaires for neck pain.
Joint Bone Spine. 2004 Jul;71(4):317-26.
5) Lower Extremity Motor Coordination Test
Desrosiers, J. et al. Validation of a new lower-extremity motor coordination test.
Arch Phys Med Rehabil. 2005 May;86(5):993-8.
6) Berg balance (out patient)
Paltamaa, J. et al Reliability of physical functioning measures in ambulatory subjects with MS.
Physiother Res Int. 2005;10(2):93-109.
PMID: 15895347
7) Tinnitte (snf, long term care)
Mold, JW et al. The prevalence, predictors, and consequences of peripheral sensory neuropathy in older
patients.
J Am Board Fam Pract. 2004 Sep-Oct;17(5):309-18.

 The ICD-9 and CPT code match up
 CCI edits with CPT codes
 Documentation:
 Functional
 Objective Test
 Valid
 Reliable

ICD-9 CPT code
Match-up
Medical
Necessity
CCI Edits
Functional Changes via
Documentation of patients
Centered Functional Goals
5/13/2015

Documentation required to indicate objective, measurable
beneficiary physical function including, e.g.,
 Functional assessment individual item and summary
scores (and comparisons to prior assessment scores)
from commercially available therapy outcomes
instruments other than those listed above; or
 Functional assessment scores (and comparisons to
prior assessment scores) from tests and measurements
validated in the professional literature that are
appropriate for the condition/function being
measured; or

 Other measurable progress towards identified
goals for functioning in the home environment
at the conclusion of this therapy episode of
care.
 Clinician’s clinical judgments or subjective
impressions that describe the current functional
status of the condition being evaluated, when
they provide further information to
supplement measurement tools; and

 A determination that treatment is not needed, or, if
treatment is needed a prognosis for return to
premorbid condition or maximum expected condition
with expected time frame and a plan of care.
 Clinician’s clinical judgments or subjective impressions
that describe the current functional status of the
condition being evaluated, when they provide further
information to supplement measurement tools; and
 A determination that treatment is not needed, or, if
treatment is needed a prognosis for return to
premorbid condition or maximum expected condition
with expected time frame and a plan of care.

 Documentation supporting medical care prior to
the current episode, if any, (or document none)
including, e.g.,
 Record of discharge from a Part A qualifying inpatient,
SNF, or home health episode within 30 days of the onset
of this outpatient therapy episode, or
 Identification of whether beneficiary was treated for this
same condition previously by the same therapy discipline
(regardless of where prior services were furnished; and
 Record of a previous episode of therapy treatment from
the same or different therapy discipline in the past year.

 Documentation required to indicate beneficiary
health related to quality of life, specifically,
 The beneficiary’s response to the following question
of self-related health: “At the present time, would
you say that your health is excellent, very good, fair,
or poor?” If the beneficiary is unable to respond,
indicate why; and

 Documentation required to indicate
beneficiary social support including,
specifically,
 Where does the beneficiary live (or intend to live) at the
conclusion of this outpatient therapy episode? (e.g.,
private home, private apartment, rented room, group
home, board and care apartment, assisted living, SNF),
and
 Who does beneficiary live with (or intend to live with) at
the conclusion of this outpatient therapy episode? (e.g.,
lives alone, spouse/significant other, child/children,
other relative, unrelated person(s), personal care
attendant), and

 Does the beneficiary require this outpatient therapy
plan of care in order to return to a premorbid (or
reside in a new) living environment, and
 Does the beneficiary require this outpatient therapy
plan of care in order to reduce Activities of Daily
Living (ADL) or Instrumental Activities of Daily
Living or (IADL) assistance to a premorbid level or
to reside in a new level of living environment
(document prior level of independence and current
assistance needs); and

Progress Note:
 Timing. The minimum Progress Report Period shall be at least
once every 10 treatment days or at least once during each 30
calendar days, whichever is less.
 The day beginning the first reporting period is the first day of the
episode of treatment regardless of whether the service provided
on that day is an evaluation, re-evaluation or treatment.
Regardless of the date on which the report is actually written (and
dated),
 the end of the Progress Report Period is either a date chosen by
the clinician, the 10th treatment day, or the 30th calendar day of the
episode of treatment, whichever is shorter.
 The next treatment day begins the next reporting period. The
Progress Report Period requirements are complete when both the
elements of the Progress Report and the clinician’s active
participation in treatment have been documented.

 The Discharge Note or Discharge Summary:
 is required for each episode of outpatient treatment. In
provider settings where the physician/NPP writes a
discharge summary and the discharge documentation meets
the requirements of the provider setting, a separate
discharge note written by a therapist is not required.
 The Discharge Note shall be a Progress Report written by a
clinician, and shall cover the reporting period from the last
Progress Report to the date of discharge.
 In the case of a discharge unanticipated in the plan or
previous Progress Report, the clinician may base any
judgments required to write the report on the Treatment
Notes and verbal reports of the assistant or qualified
personnel.

 At the discretion of the clinician, the discharge
note may include additional information; for
example, it may summarize the entire episode of
treatment, or justify services that may have
extended beyond those usually expected for the
patient’s condition.
 Clinicians should consider the discharge note
the last opportunity to justify the medical
necessity of the entire treatment episode in case
the record is reviewed. The record should be
reviewed and organized so that the required
documentation is ready for presentation to the
contractor if requested.

 The purpose of these notes is simply to create a
record of all treatments and skilled interventions
and to record the time of the services in order to
justify the use of billing codes on the claim.
 Documentation is required for every treatment
day, and every therapy service.
 The Treatment Note is not required to document
the medical necessity or appropriateness of the
ongoing therapy services.
 Descriptions of skilled interventions should be
included in the plan or the Progress Reports and
are allowed, but not required daily.

 Non-skilled interventions need not be recorded
in the Treatment Notes as they are not billable.
 However, notation of non-skilled treatment or
report of activities performed by the patient or
non-skilled staff may be reported voluntarily as
additional information if they are relevant and
not billed.
 Specifics such as number of repetitions of an
exercise and other details included in the plan
of care need not be repeated in the Treatment
Notes unless they are changed from the plan.

 Documentation of each Treatment
shall include the following required
elements:
 Date of treatment; and
 Identification of each specific intervention/modality
provided and billed, for both timed and untimed
codes, in language that can be compared with the
billing on the claim to verify correct coding. Record
each service provided that is represented by a timed
code, regardless of whether or not it is billed,
because the unbilled timed services may impact the
billing; and

 Total timed code treatment minutes and total
treatment time in minutes. Total treatment time
includes the minutes for timed code treatment and
untimed code treatment.
 Total treatment time does not include time for
services that are not billable (e.g., rest periods). For
Medicare purposes, it is not required that unbilled
services that are not part of the total treatment
minutes be recorded, although they may be included
voluntarily to provide an accurate description of the
treatment, show consistency with the plan, or
comply with state or local policies.

 The amount of time for each specific
intervention/modality provided to the patient may
also be recorded voluntarily, but contractors shall
not require it, as it is indicated in the billing.
 The billing and the total timed code treatment
minutes must be consistent. See Pub. 100-04, chapter
5, section 20.2 for description of billing timed codes;
and

 Signature and professional identification of the
qualified professional who furnished or
supervised the services and a list of each person
who contributed to that treatment (i.e., the
signature of Kathleen Smith, PTA, with notation of
phone consultation with Judy Jones, PT,
supervisor, when permitted by state and local
law).
 The signature and identification of the supervisor
need not be on each Treatment Note, unless the
supervisor actively participated in the treatment.

 Since a clinician must be identified on the Plan of Care
and the Progress Report, the name and professional
identification of the supervisor responsible for the
treatment is assumed to be the clinician who wrote the
plan or report. When the treatment is supervised
without active participation by the supervisor, the
supervisor is not required to cosign the Treatment
Note written by a qualified professional.
 When the responsible supervisor is absent, the
presence of a similarly qualified supervisor on the
clinic roster for that day is sufficient documentation
and it is not required that the substitute supervisor
sign or be identified in the documentation.

 If a treatment is added or changed under the
direction of a clinician during the treatment days
between the Progress Reports, the change must be
recorded and justified on the medical record, either
in the Treatment Note or the Progress Report, as
determined by the policies of the
provider/supplier.
 New exercises added or changes made to the
exercise program help justify that the services are
skilled. For example: The original plan was for
therapeutic activities, gait training and
neuromuscular re-education. “On Feb. 1 clinician
added electrical stim. to address shoulder pain.”

 Documentation of each treatment may also include
the following optional elements to be mentioned
only if the qualified professional recording the
note determines they are appropriate and relevant.
If these are not recorded daily, any relevant
information should be included in the progress
report.
 Patient self-report;
 Adverse reaction to intervention;
 Communication/consultation with other
providers(e.g., supervising clinician, attending
physician, nurse, another therapist, etc.);

 Significant, unusual or unexpected changes in clinical status;
 services that are not part of the total treatment minutes
be recorded, although they may be included
voluntarily to provide an accurate description of the
treatment, show consistency with the plan, or comply
with state or local policies. The amount of time for each
specific intervention/modality provided to the patient
may also be recorded voluntarily, but contractors shall
not require it, as it is indicated in the billing. The
billing and the total timed code treatment minutes
must be consistent. See Pub. 100-04, chapter 5, section
20.2 for description of billing timed codes

NCCI #59 Modifier
Medicare Cap KX modifier

 Under certain circumstances, the physician
may need to indicate that a procedure or
service was distinct or independent from other
services performed on the same day. Modifier
59 is used to identify procedures/services that
are not normally reported together, but are
appropriate under the circumstances.

 NCCI edits define when two procedure
HCPCS/CPT codes may not be reported
together except under special circumstances.
 For the NCCI its primary purpose is to indicate
that two or more procedures are performed at
different anatomic sites or different patient
encounters.

 Example: Column 1 Code/Column 2 Code 97140/97530
 CPT Code 97140 – Manual therapy techniques (eg,
mobilization/manipulation, manual lymphatic drainage,
manual traction), one or more regions, each 15 minutes
 CPT Code 97530 – Therapeutic activities, direct (one-on-one)
patient
contact by the provider (use of dynamic activities to improve
functional performance), each 15 minutes
 Policy: Mutually exclusive procedures
 Modifier -59 is:
 Only appropriate if the two procedures are performed in
distinctly
different 15 minute intervals.
 The two codes cannot be reported together if performed
during the
same 15 minute time interval.

 Use the KX modifier only in cases where the
condition of the individual patient is such that
services are APPROPRIATELY provided in an
episode that exceeds the cap.
 Routine use of the KX modifier for all patients
with these conditions will likely show up on
data analysis as aberrant and invite inquiry. Be
sure that documentation is sufficiently detailed
to support the use of the modifier.

 COMPLEXITIES are complicating factors that
may influence treatment, e.g., they may
influence the type, frequency, intensity and/or
duration of treatment.
 Complexities may be represented by diagnoses
(ICD-9 codes), by patient factors such as age,
severity, acuity, multiple conditions, and
motivation, or by the patient’s social
circumstances such as the support of a
significant other or the availability of
transportation to therapy.

Documentation supporting illness severity or
complexity including, e.g.,
Identification of other health services concurrently
being provided for this condition (e.g., physician,
PT, OT, SLP, chiropractic, nurse, respiratory
therapy, social services, psychology,
nutritional/dietetic services, radiation therapy,
chemotherapy, etc.), and/ or
Identification of durable medical equipment
needed for this condition, and/or
Identification of the number of medications the
beneficiary is talking (and type if known); and/or

If complicating factors (complexities) affect treatment, describe
why or how. For example: Cardiac dysrhythmia is not a
condition for which a therapist would directly treat a patient,
but in some patients such dysrhythmias may so directly and
significantly affect the pace of progress in treatment for other
conditions as to require an exception to caps for necessary
services. Documentation should indicate how the progress was
affected by the complexity. Or, the severity of the patient’s
condition as reported on a functional measurement tool may be
so great as to suggest extended treatment is anticipated; and/or
Generalized or multiple conditions. The beneficiary has, in
addition to the primary condition being treated, another disease
or condition being treated, or generalized musculoskeletal
conditions, or conditions affecting multiple sites and these
conditions will directly and significantly impact the rate of
recovery; and/or.

Mental or cognitive disorder. The beneficiary has a
mental or cognitive disorder in addition to the
condition being treated that will directly and
significantly impact the rate of recovery; and/or.
Identification of factors that impact severity
including e.g., age, time since onset, cause of the
condition, stability of symptoms, how
typical/atypical are the symptoms of the diagnosed
condition, availability of an intervention/treatment
known to be effective, predictability of progress.

1) Nagi, S. Disability concepts revisited: implication for prevention. In: Pope AM, Tarlov AR, eds.
Disability in America: Toward a National Agenda for Prevention. Washington, DC: National
Academy Press, 1991.
2) Guide to Physical Therapy Practice. 2nd ed. Physical Therapy. 2001;81:9-744.
3) Jette AM. Physical disablement concepts for physical therapy research and practice. Phys Ther.
1994;74:380-386.
4) Ware JE Jr, Sherbourne CD. The MOS 36-item short form health survey (SF-36), I: conceptual
framework and item selection. Med Care. 1992:30:473-483.
5) Roland M, Morris R. A study of the natural history of back pain, part 1: development of a
reliable and sensitive measure of disability in low back pain. Spine. 1983;8:141-144.
6) Stratford PW, Binkley JM, Solomon P, et al. Defining the minimum level of detectable change
for the Roland-Morris questionnaire. Phys Ther. 1996;76:365.
7) International Classification of Impairments Disabilities and Handicaps. Geneva, Switzerland,
World Health Organization, 1980.
8) Moorhead, JF, Clifford, J. Determining Medical Necessity of Outpatient Services. American
College of Medical Quality. 1992;7(3);81-4.
9) Cyriax, J. The advantage of accurate treatment. Physiotherapy. 1952 Jan;38(1):3-8
10) Zitsmann, SL. Utilization Management of Worker’s Compensation: Out patient Therapy.
JHQ:1993;15(3):34-7.
11) http://www.rehabmeasures.org/default.aspx

 Contact Information
Dr. Charles Curtis MS, PT, DPT, MDT
33 Orchard Place Little Silver, NJ 07739
732-320-0768
ccurtis33@verizon.net

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